The Marketplace - Insurance Exchanges and Providers
 

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Exploring coverage options through the Marketplace a/k/a Health Insurance Exchange (HIX) is among a growing lexicon of terms for governmental and insurance stakeholders. Intended to provide the ...

Exploring coverage options through the Marketplace a/k/a Health Insurance Exchange (HIX) is among a growing lexicon of terms for governmental and insurance stakeholders. Intended to provide the consumer with an intuitive way to shop coverage with built-in protections, HIX open enrollment launches Oct. 1, 2013 and offers assistance with coverage choices and comparisons, calculation of costs, and education on public program options. Some HIXs will be run by state governments while others will be administered wholly or in partnership with the federal government. Explore the four exchange tiers, what constitutes "essential benefits" and "essential community providers," the role consumer assistants such as navigators in facilitating coverage for each American, and what providers and practices should be doing today to prepare. Review the basic functions of the HIX and the available subsidies for individuals and families. Regulations on Medicaid eligibility expansion will also be covered, as well as the impact on adult coverage and the future HIX milestones.

Source: Webinar presented August 28, 2013 by Adele Allison, National Director of Government Affairs for SuccessEHS

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The Marketplace - Insurance Exchanges and Providers Presentation Transcript

  • 1. 888.879.7302 • www.SuccessEHS.com The Marketplace – Insurance Exchanges and Providers Adele Allison National Director of Government Affairs August 28, 2013
  • 2. 888.879.7302 • www.SuccessEHS.com • ACA Jargon • Timelines – Health Plans and Employers • States and Medicaid Expansion • Benefit Tiers, Individuals and SHOPs • Consumer Assistance and Provider Impact • Questions Marketplace – Health Ins. Exchanges
  • 3. 888.879.7302 • www.SuccessEHS.com Polling the Audience
  • 4. 888.879.7302 • www.SuccessEHS.com Statutory Law vs. Case Law 100 435 CONGRESS Statutory Law Health Care Policy Act 30 Lawsuits 2 Cases Case Law ELECTEDOFFICIALS→TERMS APPOINTEDOFFICIALS→LIFETIME Appeals
  • 5. 888.879.7302 • www.SuccessEHS.com Supreme Court of the U.S. - SCOTUS Chief Justice John Roberts Justice Antonin Scalia Justice Anthony Kennedy Justice Clarence Thomas Justice Ruth Ginsburg Justice Stephen Breyer Justice Samuel Alito Justice Sonia Sotomayor Justice Elena Kagan
  • 6. 888.879.7302 • www.SuccessEHS.com Understanding Common Terms • Affordable Care Act of 2010 (ACA) → 2 Laws passed by the 111th U.S. Congress in March, 2010 o Patient Protection and Affordable Care Act (PL 111-148) o Health Care and Education Reconciliation Act (PL 111-152) o SCOTUS – Oral Argument late Mar., 2012; Final Ruling 6.28.2012 • Health Insurance Exchange (HIX) a/k/a Health Insurance Marketplace o Feds → “Marketplace” not “Exchange” o Online resource for Individuals, Families, Small Businesses o Compare Qualified Health Plans (QHPs) costs, benefits, etc. o Select and enroll in coverage • Affordable Coverage → 9.5% of household income for Employer Groups
  • 7. 888.879.7302 • www.SuccessEHS.com Understanding Common Terms • Individual Mandate o Under ACA, most Americans must have health insurance o Failure to have coverage could result in a “penalty” or tax o Exempt → Religious Exemption, Illegals, Incarcerated • Medicaid Eligibility Expansion (State Option) o New eligible group → Adults not already eligible without dependent children o Minimum income threshold → is it 133% or 138% of FPL? • Modified Adjusted Gross Income (MAGI) o System for determining eligibility for Medicaid expansion benefits and federal subsidies o Uniform across the states o A single, standard income disregard for most populations of 5% → (138% FPL – 5% = 133%)
  • 8. 888.879.7302 • www.SuccessEHS.com Understanding Common Terms • Qualified Health Plans (QHPs) o Insurance plan that is “certified” by the Marketplace o Provides essential health benefits • Marketplace Tiers o 4 Coverage levels → Bronze, Silver, Gold and Platinum o Bronze covers 60%, Silver 70%, Gold 80% and Platinum 90% o QHPs need not offer all tiers, but must offer 1 Silver + 1 Gold • Open Enrollment o Period when eligible to enroll in QHP in the Marketplace o 2014 → Oct. 1, 2013 – Mar. 31, 2014 o 2015 and beyond → Oct. 15 – Dec. 7 preceding year of coverage o “Special Enrollment” is available for 30 days following a life event
  • 9. 888.879.7302 • www.SuccessEHS.com Understanding Common Terms • Essential Health Benefits (EHBs) o A minimum set of core benefits → mimics employer-sponsored coverage o Includes 10 categories of services • Minimum Essential Coverage → 60% of Actuarial Value Ambulatory Services (E.g., MD Visits) Emergency Services Hospitalization Maternity / Newborn Care Mental Health / Substance Prescription Medications Rehab Services and Devices Laboratory Services Preventive, Wellness and Chronic Disease Mgmt. Pediatric Care (Including Oral and Vision)
  • 10. 888.879.7302 • www.SuccessEHS.com Understanding Common Terms • Essential Community Providers (ECPs) o QHPs must have an “adequate network” of providers o Sufficient providers for low-income, underserved patients o CMS Defines 6 major ECP categories: o Overseen by Center for Consumer Information & Insurance Oversight (CCIIO) o Must contract with ECPs on CCIIO’s non-exhaustive database (denominator) if Federal-run or run through partnership (http://1.usa.gov/18gv4MZ) o Operationalized for plan year 2014 by CMS – Letter to Issuers Federally Qualified Health Centers Ryan White Providers Family Planning Providers Indian Providers Hospitals Other
  • 11. 888.879.7302 • www.SuccessEHS.com Measuring Knowledge
  • 12. 888.879.7302 • www.SuccessEHS.com • ACA Jargon • Timelines – Health Plans and Employers • States and Medicaid Expansion • Benefit Tiers, Individuals and SHOPs • Consumer Assistance and Provider Impact • Questions Marketplace – Health Ins. Exchanges
  • 13. 888.879.7302 • www.SuccessEHS.com 2012 ACA Requirements Insurance MLR 85% in Claims Paid or Rebate Women’s Prev. Free Contraceptives Sum. of Benefits and Coverage Uniform with Plans, 60 days notice of changes Comparative Effectiveness Fee $1/covered life/year from Employers for PCORI ($2/life in 2013) W-2 Reporting Must reflect cost of Health Care
  • 14. 888.879.7302 • www.SuccessEHS.com 2013 ACA Requirements Health Care Exchange Notice Requirement to provide employees written notice about the HIX Health Flex. Spending Acct. (FSA) Contributions capped at $2,500/year Medicare Payroll Tax 3.8% Medicare tax on unearned income for high-income ind. Hospital Insurance Tax Must reflect cost of Health Care
  • 15. 888.879.7302 • www.SuccessEHS.com 2014 Grandfathered Plans Changes • No annual limits on Essential Health Benefits • No pre-existing condition exclusions for children under 19 • New hire waiting periods limited to 90 calendar days • Fair Labor Standards Act amended → 200+ FTEs must automatically enroll new FT employees • Reinsurance Fee (2.2% Tax) of $5.25 PMPM assessed 2014 o Runs through 2016, but decreases o Used to partially subsidize individual insurers of high-cost individuals o Will impact premium rates • Limits on cost-sharing and annual deductibles • Age-rating ratio limited to 3:1; Tobacco rating limited to 1:1.5 • No gender rating
  • 16. 888.879.7302 • www.SuccessEHS.com Employer Mandate – Delayed • Employer Mandate required 50+ Businesses offer coverage by 2014 or pay penalty • Delayed 1 year (Jul. 2) → BUT Ind. Mandate still in place • 2 Direct Impacts o Uptick in federally subsidized enrollment under the HIX o Lower the unemployment rate  Employers not offering “minimum essential coverage” penalties • $2,000/worker, $3,000/work if employee receives fed. Subsidies • E.g., 50 Employees – 20 (first 30 are exempt from penalties) x $2,000 = $40,000 in Fines  Employer Strategy → stay below 50 full-time employees; hire part- time workers
  • 17. 888.879.7302 • www.SuccessEHS.com Measuring Knowledge
  • 18. 888.879.7302 • www.SuccessEHS.com • ACA Jargon • Timelines – Health Plans and Employers • States and Medicaid Expansion • Benefit Tiers, Individuals and SHOPs • Consumer Assistance and Provider Impact • Questions Marketplace – Health Ins. Exchanges
  • 19. 888.879.7302 • www.SuccessEHS.com ACA and Medicaid Expansion • SCOTUS → States may truly “Opt-Out” • Financial Considerations o Should create a net savings o Could increase hospital revenues, offsetting ACA hospital reductions o Some states concerned about federal deficit reduction efforts impact • Impact on Coverage o ↑ Access to care for low-income Americans o No Implementation → Large gaps in coverage • State Flexibilities o Benefit design, cost-sharing, care delivery models, and reimbursement o Ability to seek approval for demonstration waivers (2017) → 1115 waivers can be mixed with State Innovation Waivers
  • 20. 888.879.7302 • www.SuccessEHS.com Where do States stand? • 19 Opting-in • 16 Opting-out • 5 Leaning Towards Opting-in • 7 Leaning Towards Opting-out • 3 Considering Alternative Model
  • 21. 888.879.7302 • www.SuccessEHS.com Where do States stand?
  • 22. 888.879.7302 • www.SuccessEHS.com Measuring Knowledge
  • 23. 888.879.7302 • www.SuccessEHS.com • ACA Jargon • Timelines – Health Plans and Employers • States and Medicaid Expansion • Benefit Tiers, Individuals and SHOPs • Consumer Assistance and Provider Impact • Questions Marketplace – Health Ins. Exchanges
  • 24. 888.879.7302 • www.SuccessEHS.com HIX and States • Each State will have 1 Marketplace • 3 Type of Marketplaces, variance by State o Federally Facilitated o Federal-State Partnership o State-based • Coverage facilitated for 2 types of consumers o Individuals and Families o Small Businesses • 27 are Federally Run; 16 are State-based; 7 are Federal- State Partnerships
  • 25. 888.879.7302 • www.SuccessEHS.com Health Ins. Marketplace by State State-Run Partnership State-Run SHOP Fed-run Ind. Federal-Run Federal Run State Plan Mgmt.
  • 26. 888.879.7302 • www.SuccessEHS.com Core Marketplace Requirements • Enrollee Assistance o 34 states with Federal involvement → $54 Million in HHS funding for Navigators o 16 states and D.C. operating state-based → snag in Federal funding = “in-person assister” for first year o CHCs, hospitals, other orgs. can offer a certified application counselor • Management of plans → private and public • Eligibility determination and verification • Beneficiary enrollment o CBO estimates add’l 13 million to enroll in Medicaid and CHIP over next 10 years o Cost increase of $74 billion over previous estimates • Overall financial management
  • 27. 888.879.7302 • www.SuccessEHS.com Individual Mandate – Penalties • Individual Mandate Penalty Tax o 2014 → Greater of $95/individual (capped at 3), or 1% of household income o 2015 → Greater of $325/individual, or 2% of household income o 2016 and beyond → Greater of $695/individual, or 2.5% of household income o 2017 → penalties will be increased by cost-of-living adjustment • Exemptions o Religious, unlawfully present in U.S., and Incarcerated o Cannot afford based on legal formulas o Income below federal income tax filing threshold o Members of Indian tribes o Uninsured for less than 3 months, hardship waiver, residing outside of U.S.
  • 28. 888.879.7302 • www.SuccessEHS.com The Marketplace – Benefit Tiers Platinum 90% Gold 80% Silver 70% Bronze 60% • 30 and Under o Ind. Catastrophic o Certain Mandate Exemptions • QHPs → must offer minimum of 1 Silver and 1 Gold level plan
  • 29. 888.879.7302 • www.SuccessEHS.com Qualified Health Plans • Only Qualified Health Plans (QHPs) can be on HIX • HHS requirements of QHPs o Accredited by URAC or NCQA o Demonstrate Network Adequacy o Have sufficient number of Essential Community Providers (ECPs) • State Guidance on Network Adequacy → Review and approval by 1 of 2 accrediting agencies • First Effective date Jan. 1, 2014 • Open Enrollment begins Oct. 1, 2013
  • 30. 888.879.7302 • www.SuccessEHS.com Federal Subsidies • Federal Subsidies → Available for incomes between 100% and 400% of FPL (E.g. Family of 4, income of $89,000) o Premiums deemed unaffordable → more than 9.5% of household income, or o Plan is inadequate → covers less than 60% of cost of covered benefits Income Premium Limit Up to 133% FPL 2% of Income 133-150% FPL 3 – 4% of Income 150-200% FPL 4 – 6.3% of Income 200-250% FPL 6.3 – 8.05% of Income 250-300% FPL 8.05% - 9.5% of Income 350-400% FPL 9.5% of Income Source: Community Catalyst, Center for Health Insurance Studies, Georgetown University
  • 31. 888.879.7302 • www.SuccessEHS.com Small Business Health Options Program • The Good o 2014 SHOP Marketplace → businesses with 50 or less FTEs  Allows for health plan comparison  SHOP-purchased plans can bring up to 50% tax credit (based on premiums) in 2014 o SHOP opens to employers up to 100 FTEs in 2016 o Not available for self-employed → must use ind. Marketplace o 1 online application process, 1 bill, 1 monthly payment o Small business can decide contribution toward premiums • But … o Must have office/work site within SHOP service area o Many states require at least 70% FTE enrollment o Delayed requirement of having numerous QHPs until 2015 = Opens on time, but may only be 1 QHP option
  • 32. 888.879.7302 • www.SuccessEHS.com Measuring Knowledge
  • 33. 888.879.7302 • www.SuccessEHS.com • ACA Jargon • Timelines – Health Plans and Employers • States and Medicaid Expansion • Benefit Tiers, Individuals and SHOPs • Consumer Assistance and Provider Impact • Questions Marketplace – Health Ins. Exchanges
  • 34. 888.879.7302 • www.SuccessEHS.com Consumer Assistance • 4 Types of Consumer Assistance o Navigators o Non-Navigator, In-Person Assistant o Certified Application Counselor o Agents and Brokers • Role of Consumer Assistants o Increase awareness about the Marketplace o Determine eligibility and facilitate enrollment o Alleviate consumer fear
  • 35. 888.879.7302 • www.SuccessEHS.com Consumer Assistance • Navigators o At least 2 Navigator organizations (minimum) o 1 must be Non-Profit, Community Org. o Health Insurers cannot be Navigators o Requires 30 hours training and testing o Must be linguistically/culturally appropriate o HIXs cannot use establishment grant dollars to fund o If Federally-run HIX → State-run Navigators o Partnership HIX → Feds will establish and train; state responsible for management o State-run HIX → all done by the State
  • 36. 888.879.7302 • www.SuccessEHS.com Consumer Assistance • Non-Navigator, In-Person Assistant o Similar duties to navigators with similar training o Must pass a conflict-of-interest check o HIX can use establishment grants for funding in the 1st year o Federally-run HIX → Not required o Partnership HIX → Required o State-run HIX → Optional • Certified Application Counselor o Required for all of the exchanges o Training → 5-7 hours + test; materials open to all o Cannot discriminate on assisting patients (E.g. HIV clinic cannot limit help to HIV patients) o No separate funding o Additional details at www.cms.gov/cciio/resources/marketplace-grants/
  • 37. 888.879.7302 • www.SuccessEHS.com Consumer Assistance • Agents and Brokers o State-by-state as allowed by the State o Must show all QHPs offered and be knowledgeable o Must take a test • Consumer Assistance by Marketplace-Type Type of Marketplace Navigators In-Person Assistant Certified Application Counselor Agents and Brokers State-based Yes Optional Yes Optional Federal-State Partnership Yes Yes Yes Yes, if state permits Federal-run Yes No Yes Yes, if state permits Source: HRSA, ACA: Outreach, Education and Enrollment Presentation, Aug. 6
  • 38. 888.879.7302 • www.SuccessEHS.com Impact on Federal Budget – CBO • ACA’s Coverage Provisions (May, 2013) → $1.4 Trillion over 2014-2023 • CBO Cost Impact Factors o ↑ Number of Medicaid / CHIP enrollees → 13 Million o ↓ Number of HIX enrollees because of Expansion = less subsidies • CBO Impact of the delay in Employer Mandate → +$12 Billion o Almost $10 Billion less in employer penalty payments o Almost $3 Billion more in federal subsidies paid • Estimated Uninsured in 2016 → 30 Million o Majority not subject to Individual Mandate penalty tax → 18-19 Million  Mostly unauthorized immigrants  Rest → Indian tribes, Income too low to file tax return, premium exceeds share of income Source: Congressional Budget Office Reports
  • 39. 888.879.7302 • www.SuccessEHS.com Projected Enrollment Source: CBO Report on HIX, May 2013 Baseline
  • 40. 888.879.7302 • www.SuccessEHS.com Projected Enrollment Source: CBO Report on HIX, May 2013 Baseline
  • 41. 888.879.7302 • www.SuccessEHS.com Projected Enrollment Source: CBO Report on HIX, May 2013 Baseline
  • 42. 888.879.7302 • www.SuccessEHS.com Projected Enrollment Source: CBO Report on HIX, May 2013 Baseline
  • 43. 888.879.7302 • www.SuccessEHS.com Provider Impact • Challenges o Health IT adoption and use o Increased workforce shortages and overburdened providers o Health care reform value-based re- imbursement models o Quality and Transparency o Enterprise-wide risk and liability o Continuing Education o Market Consolidation o HIX Coverage “Gotcha”
  • 44. 888.879.7302 • www.SuccessEHS.com Provider Impact • Call to Action o Patient-Centered Care o Care Coordination o Seamless financial, operational and clinical information sharing through Health IT  Must support organizations clinical AND business requirements  Must have Business Intelligence and Dashboards  Must flawlessly integrate core organizational functions  Must be secure and private  Must engage the patient
  • 45. 888.879.7302 • www.SuccessEHS.com Provider Impact • What can you do today? o Identify number of uninsured patients in your market o Understanding what kind of Marketplace your state has o Ask your Insurance Commissioners or Marketplace which QHPs are participating o Initiate contract negotiations with QHPs o Educate QHPs about your organization and role in care delivery – Are you a ECP? o Talk with patients about eligibility / enrollment options o Refer patients to Healthcare.gov for more information o Identify and refer patients to Consumer Assistance Programs in your state o Additional details at www.cms.gov/cciio/resources/marketplace-grants/
  • 46. 888.879.7302 • www.SuccessEHS.com QUESTIONS CEUs available at: webinars@successehs.com Copies available on SlideShare or www.SuccessEHS.com/webinars Follow me on Twitter: www.twitter.com/Adele_Allison Added to The BRIEF or Questions: adelea@successehs.com